Monterey police say the pursuit began around 1:30 am Sunday when officers saw the truck driving the wrong way on the street.
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The driver briefly stopped but then took off toward the end of the wharf.
When officers reached the edge of the pier, they heard screams coming from the water.
All four people in the truck were rescued.
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Investigators say the driver, 21-year-old Martin Urroz of Fresno, was taken to the hospital.
He was arrested on several charges, including driving under the influence.
His passengers only had minor injuries.