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City of Santa Ana <br />Clerk of the Council <br />AGREEMENT TERMINATION FORM <br />Please complete this form in its entirety when the attached agreement and <br />amendments (if any) are no longer in effect. <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 />Office <br />A{ OF _� 1d F �4 'NA <br />ER <br />�r <br />('2©t <br />No. N-2017-171 was completed on �t�pl i / and final payment has been made. <br />(List atl amendments. Use space below if needed.) <br />Department: WSI-A- <br />Phone/Ext.: <br />Signature:ao <br />Date: LC7j: IGj. i`g <br />Revised: 10-18-16 <br />