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City of Santa f a <br />Clerk of the Council <br />AGREEMENT TERMINATION FORM <br />Please complete this form in its entirety when the attached agreement and all <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amendments (if any) are no longer in effect.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 />Office Use Only <br />City of Santa Ana <br />5. 02 c <br />Clerk of the Council <br />The agreement with <br />No. A-Za DI was completed on \� �JI I l�1 and final payment has been made. <br />(List all amendments. Use space below if needed.) <br />Department: {'Q-(��'� I�C:tim'Lv\"" <br />Phone/Ext.: �v <br />Signature: <br />Date: 7 13G1 L <br />Revised: 10-18-16 <br />