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City of Santa Ana GLV/ <br />COTC Office Use Only <br />Clerk of the Council <br />AGREEMENT TERMINATION FORM i?r� <br />Please complete this form in its entirety when the attached agreement and all ,f' �4y <br />amendments (if any) are no longer in effect. <br />r� <br />Note: If your agreement is grant related, please ensure that all grant retention requirements <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 />N-2016-161 <br />No. was completed on 1qh tP and final payment has been made. <br />(List all amendments. Use space below if needed.) /1� <br />Department: -F'PxS q <br />Phone/Ext.:- <br />Signature: '-5j-06c, yAla/i <br />Date: [b 1 W, n <br />Revised: 10-18-16 <br />