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c2bt <br />City of Santa Ana <br />Clerk of the Council corc Office use Only <br />AGREEMENT TERMINATION FORM <br />Please complete this form in its entirety when the attached agreement and all <br />amendments (if any) are no longer in effect. <br />Note: If your agreement is grant related, please ensure that all grant retention requirements CITY OF SANTA At <br />have been satisfied prior to signing the termination form. (fibcD <br />OF i <br />Is the agreement(s) a permanent record? Yes No <br />Return form to the Clerk of the Council Office (M-30). <br />Call 647-1520 if you have any gquuestiiyo,ns. p > I� <br />The agreement with Smfn n A'*I y%t j W� 9a,5619AO „JW - <br />No. A' L' "t_ 171 was completed on -GI !:Vlu and final payment has been made. <br />(List all amendments. Use space below if needed.) / �/p ,�I V (jr <br />Department: U 1) f Y e"ylvfX rS <br />Phone/Ext.: %C <br />Signature: <br />Date: <br />Revised: 10-18-16 <br />