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U.S. DEPARTMENT OF HOMELAND SECURITY U.S. COAST GUARD CG-4143 (Rev. 6-04)

APPLICATION FOR CLASS 1 PRIVATE AIDS TO NAVIGATION ON ARTIFICIAL ISLANDS AND FIXED STRUCTURES (Please read instructions on page 2)
A. B. C. D. ESTABLISH AND MAINTAIN CHANGE OWNERSHIP CHANGE EQUIPMENT MOVE

OMB APPROVED 1625-0011

1. NAME AND ADDRESS (including zip code) OF CORPORATION OR PERSON MAKING APPLICATION

2. ACTION REQUESTED FOR PRIVATE AIDS TO NAVIGATION E. DISCONTINUE

F. DATE OF ACTION

3. POSITION
A. GENERAL LOCALITY AND GRID AREA B. LATITUDE C. LONGITUDE

D. BLOCK NUMBER

E. SIGN

F. LEASE NUMBER

G. WELL NUMBER

4. LIGHT
A. CHARACTERISTICS COLOR WHITE RED FLASH SECONDS ECLIPSE E. VOLTS SECONDS F. AMPERES LENS B. NUMBER INSTALLED C. ILLUMINANT (Check) ELECTRICITY OTHER (Specify) G. INSIDE DIAMETER GLOBE H. CANDLEPOWER (If known) GAS OIL

D. HEIGHT ABOVE MEAN HIGH WATER

5. FOG SIGNAL (Characteristic will be one two-second blast every twenty seconds)
A. CLASS A (2-Mile) B (1/2-Mile) B. MANUFACTURED BY C. MODEL NUMBER

6. STRUCTURE
A. COLOR B. HEIGHT ABOVE MEAN HIGH WATER C. DEPTH OF WATER BELOW MEAN LOW WATER

7. AUTHORIZED BY CORPS OF ENGINEERS, U.S. ARMY, PERMIT NO. 8. PERSON IN DIRECT CHARGE OF AID
A. NAME C. ADDRESS

B. TELEPHONE NUMBER

9. The applicant agrees to save the Coast Guard harmless with respect to any claims that may result arising from the alleged negligence of the operation of the approved aids. Attached to this application are:
A. D. DATE LOCATION PLAT B. PRINT OF STRUCTURE C. AIDS TO NAVIGATION EQUIPMENT LIST CERTIFICATE REQUIRED BY 33 CFR 67.10-1 (4) SIGNATURE

TITLE

FOR COAST GUARD USE
10. FROM:

Commander
A. THE ACTION DESCRIBED ABOVE IS

Coast Guard District
B. NOTICE TO MARINERS WILL BE ISSUED WILL NOT BE ISSUED D. NAME OF AID(S)

APPROVED APPROVED SUBJECT TO THE COMMENTS IN BLOCK 11 ON REVERSE C. CHARTS AFFECTED

E. DATE

F. SIGNATURE (By direction in accordance with 33 CFR 67)

PREVIOUS EDITION IS USABLE

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PAGE 2 OF CG-4143 (Rev. 6-04)

INSTRUCTIONS
1. The applicant will complete items 1 through 9. 2. Submit in triplicate to the Coast Guard District Commander, Attach a location plat, print of the structure showing positions of the aids, a complete Aids to Navigation Equipment List, and when establishing or changing a fog signal, the certificate required by 33 CFR 67.10-1(4).
11. REMARKS

3. You may obtain from the Coast Guard District Commander copies of Title 33-Navigation and Navigable Waters, Chapter 1-Coast Guard, Department of Homeland Seurity, Subchapter C-Aids to Navigation, Part 67-Private Aids toNavigation, Outer Continental Shelf and Waters Under the Jurisdiction of the United States.

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