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City of Santa Ana <br />Clerk of the Council cofcmce use Only <br />AGREEMENT TERMINATION FORM 7 7n <br />! 7 -15 , 2 3 p <br />Please complete this form in its entirety when the attached agreement and all <br />amendments (if any) are no longer in effect. <br />CITY I' JF S I <br />Note: If your agreement is grant related, please ensure that all grant retention requirements l ti± �c <br />have been satisfied prior to signing the termination form. <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 questions. <br />The agreement with <br />0 <br />No. N-2016-159 I was completed on and final payment has been made. <br />(List all amendments. Use space below if neededj <br />Department: F12—M-Pf <br />Phone/Ext.: G& q <br />Signature: SQA)iI� LJ VlCkO <br />Date: 101101--] <br />Revised: 1418-16 <br />