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City of Santa A ^a <br />Clerk of the Coin.. it <br />AGREEMENT TERMINATION FORM <br />Please complete this form in its entirety when the attached agreement anr� III <br />amendments (if any) are no longer in effect. LL''NN <br />Note: If your agreement is grant related, please ensure that all grant retention requirements CITY <br />have been satisfied prior to signing the termination form. rI N <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-2017-213 was completed on <br />(List all amendments. Use space below if needed.) <br />'b Pit 3..39 <br />1=.JiA ANA <br />G COUNCIL <br />a3 and final payment has been made. <br />Department: i f>A <br />Phone/Ext.: y{q <br />Signature: pr!✓����%z— <br />Date: <br />Revised: 10-I8-16 <br />