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City of Santa Ana <br />... - -- <br />Clerk of the Council coTc office use only <br />!� 'w <br />AGREEMENT TERMINATION FORM <br />Please complete this form in its entirety when the attached agreement and all 7119 AM 22 PM q: n7 <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amendments (if any) are no longer in effect.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 CR S AN I A AN A <br />have been satisfied prior to signing the termination form. CLERK OF COUNCIL <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 />No. N-2016-183 was completed on p va1 ' and final payment has been made. <br />(List all amendments. Use space below if needed.) D <br />Department: 1 RG ",5 A <br />Phone/Ext.: <br />Signature: ty ld1t� reylixy, <br />Date: <br />Revised: 10-18-16 <br />