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City of Santa Ana <br />�9 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amendments (if any) are no longer in effect.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 />The agreement with Tom Cj-5 ell ro� <br />N-2018-053 <br />No. <br />(List all amendments. <br />was completed on 4140116 <br />Use space below if needed.) <br />II SEP 27 PM 3-* 10 <br />OF SANTA ANA <br />RK OF CCUNU <br />and final payment has been made. <br />Department: �(,DA <br />Phone/Ext.: �/3®5 <br />Signature: 0���� <br />Date: 01 oVD <br />Revised: 10-18-16 <br />